Concussion in Sport and hypopituitarism

Joanna Lane, campaigner

headinjuryhypo

There is a growing body of research highlighting that "sports-related
repetitive TBI has a cumulative effect on the development of pituitary
dysfunction." [1]

The Consensus Statement of 2008 did not allude to post-traumatic
hypopituitarism (PTHP), but it is an important and treatable complication
of concussion which every GP and A&E department should be alert for, for
the following reasons:

- PTHP could be a contributory factor to the tripled/quadrupled
suicide risk after all traumatic brain injury including concussion [3].

- So many people are potentially affected. Sports concussions are a
commonplace event, and some studies put the incidence of PTHP after mild
traumatic brain injury as high as 16.8% [4] Sports concussions also affect
a section of the population i.e. young men under 35, who are already
listed as a high risk group for suicide in the national suicide prevention
strategy document [5].

Being alert for PTHP especially among teenage boys and young men (and
girls too) might do much to reduce the suicide rate.

Conflict of Interest:

More science please

Justin A Paoloni

Dear Editor

I read with interest the Consensus Statement on Concussion, and
believe this worthwhile in furthering scientific knowledge on concussion
in sport. However, I have concerns about definitive comments in the
consensus statement, given the lack of supporting scientific evidence.
Whilst this consensus document is only “a guide and is of a general nature
consistent with the reasonable practice of a healthcare professional”, it
is also “reflects the current state of knowledge”. This comment does not
accurately represent the documents’ contents with definitive statements
not evidenced based.

I agree with the preamble; “management and return to play decisions
remain in the realm of clinical judgement on an individualized basis”, as
scant high level evidence is available on concussion management. However,
Section 2.2 states that “a player with diagnosed concussion should not be
allowed to return to play on the day of injury. Occasionally, in adult
athletes, there may be a return to play on the same day of injury (see
Section 4.2)”, which follows with “adult athletes, in some settings, where
there are team physicians experienced in concussion management and
sufficient resources…return to play may be more rapid.” These statements
have multiple qualifiers, but do not represent the management of
concussion in sport. More than “occasionally” do athletes return to play
on the same day after medical assessment and symptom resolution, and this
appears safe and effective. The return to play decision does not require
the “sufficient resources” mentioned, but does require a physician
experienced in concussion management. Certainly, there are no scientific
studies, and no comparison studies, with high enough level of evidence to
definitively support either approach.

Section 11 states that “the consensus statement is intended to serve
as the scientific record of the conference”. Thus, these definitive
statements on concussion management, from an expert panel, require
supporting scientific evidence and appropriate referencing, as for any
scientific paper. To make these statements without quoting relevant high
level evidence is not scientific. There are potential legal ramifications
for medical practitioners who do not follow these concussion management
guidelines.